Concomitant traumatic coronary artery and tricuspid valve injury: a heterogeneous presentation.

Blunt thoracic trauma resulting in both tricuspid valve rupture and coronary artery injury is uncommon, encompasses a large spectrum of presentations and, therefore, can be difficult to diagnose. This report illustrates the heterogeneous presentation and clinical course of two patients with such a combination of cardiac injuries. The patient with associated right coronary artery dissection developed progressive right ventricular failure over a 12-year period before successful surgical repair, whereas another patient with left anterior descending coronary artery thrombosis required urgent operation for acute right ventricular dysfunction and hemodynamic decompensation.

Injury of a medial sacral vessel during lumbar laminectomy.

Vascular injury sustained during neurosurgical procedures is surprisingly rare, especially considering the anatomic proximity of major blood vessels to the vertebral column. Mortality rates are high if the injury is not recognized and definitive management is delayed. Case reports include massive hemorrhage, arteriovenous fistulas, and development of false aneurysms. Diagnostic CT scan and arteriography are useful if the patient's condition permits; however, rapid intervention is crucial to the patient's survival. After reviewing the current surgical literature, we present a case of medial sacral artery injury occurring during laminectomy.

Primary aortoenteric fistulas: a case report.

Primary aortoenteric fistulas are rare vascular entities. Their recognition involves astute clinical observation. Diagnostic testing is frequently nonconfirmatory and usually impedes urgently needed operative intervention. We present a case of primary aortoenteric fistula and emphasize the necessity for immediate surgical evaluation.

End-stage renal disease with venous occlusion in both upper extremities.

We studied 27 patients with venographically documented bilateral subclavian vein occlusion thrombosis after the use of dual lumen hemodialysis catheters. Immediate venous access was severely limited because all patients had previously had multiple access failures. The rate of venous pressure rise between hemodialysis treatments is inconsistent in suggesting imminent thrombosis as the sole explanation for venous thrombosis, yet it is a signal to investigate vein patency. Venography may be the best method, pending further development of duplex ultrasonography. The lack of clinical symptoms warrants early use of duplex ultrasonography and venography to document subclavian vein occlusion thrombosis so that heparin and thrombolytic therapy may be initiated. Length of time between onset of pressure increase and initiation of therapy did not affect successful outcome.

Role of three hour roentgenogram of the chest in penetrating and nonpenetrating injuries of the chest.

The current study examined whether a three hour roentgenogram of the chest was as reliable as the six hour roentgenogram of the chest in detecting delayed complications (that is, pneumothorax and hemothorax) of penetrating and nonpenetrating trauma to the chest. The 285 patients in the study were placed into three groups: those stabbed in either the chest or back; those sustaining multiple fractures of the ribs, and those with gunshot wounds to the chest or back. All the patients selected for study by three and six hour films of the chest were asymptomatic on admission and no pneumothorax or hemothorax was seen on initial anteroposterior and lateral roentgenograms of the chest. None of the patients included in the study required immediate operation. Twelve patients (4 percent) had delayed pneumothoraces on the three hour roentgenogram of the chest. Nine of these 12 (75 percent) required thoracostomy tube drainage, while the remaining three patients were managed with needle aspiration. No additional patients had complications on the six hour roentgenogram of the chest. Computed tomographic (CT) scan discovered five additional patients (2 percent) with pneumothoraces not visualized by the three or six hour films. Seventeen patients (6 percent) had delayed pneumothoraces despite negative admission roentgenograms of the chest and lack of symptoms. Twelve of the 17 (71 percent) were discovered on three hour roentgenogram of the chest, while an additional five of 17 (29 percent) were only seen by CT scan. Three hour roentgenograms of the chest are as reliable as six hour roentgenograms of the chest in visualizing the development of delayed complications of penetrating and nonpenetrating thoracic trauma. The CT scan is more effective than the roentgenogram of the chest in visualizing small pneumothoraces, but its use as a screening tool for detection of delayed complications of trauma to the chest pneumothoraces is probably cost-prohibitive.

A traumatic splenic rupture in a healthy adult.

Splenic rupture in blunt and penetrating trauma is well documented. Other etiologies include hematologic and inflammatory disorders. The case presented documents occult splenic rupture. There was no history of trauma. Furthermore, no evidence of systemic disease or pathology could be found. Occult, spontaneous splenic rupture is rarely diagnosed, although the associated mortality/morbidity is high. The astute clinician must have a high index of suspicion relying on clinical and roentgenographic study for rapid diagnosis and management.

Patient compliance with fitted compression hosiery monitored by photoplethysmography.

This study assessed the compliance useage and impact by monitoring of graded compression hosiery in chronic venous disease. Diagnostic methods, such as qualitative photoplethysmography (PPG), have enabled the physician to assess deep-vein valvular incompetence earlier and begin specific treatment measures to slow the progression of symptoms. This study group, comprised of 100 patients, was diagnosed initially with deep-venous thrombophlebitis and evaluated by phleborrheography and PPG at three-month intervals for one year. The patients were instructed to wear fitted, graded compression hosiery after hospital discharge; compliance was 37% at one year. The primary reason for noncompliance was socioeconomic. The price of the ideal graded compression hosiery was not easily within reach of this population and insurance reimbursement was difficult or impossible to obtain. Complaint patients felt better while wearing the compression hosiery. Increasing deterioration of qualitative PPG values of deep-valve assessment was found in both compliant and noncompliant patients at each testing interval. The PPG value deteriorated as time increased with or without the compression hose, although symptoms lessened when the prescribed hosiery was worn. The long-term sequelae of wearing or not wearing the hosiery are yet to be determined, but PPG assessment is normalized with the hosiery in place.

Obstructive jaundice caused by hepatoma fragments in the common hepatic duct.

A 67-year-old black male diabetic who had never consumed alcohol presented with anorexia, weakness, weight loss, and jaundice. Ultrasound demonstrated common bile duct obstruction; computed tomography scanning revealed multiple liver masses; endoscopic retrograde cholangiopancreatography showed a filling defect; aortogram confirmed the neovascularity of tumor proliferation; and percutaneous transhepatic cholangiography confirmed high-grade common duct obstruction. Operative intervention demonstrated hepatocellular emboli to the common bile duct causing obstruction. We review the literature on this problem.